Diagnosis: left arm amputation

Treatment: prosthetic arm

The insurer is denied coverage for prosthetic arm

The denial is overturned.

This male patient has a history of atrio-ventricular (AV) malformation and left arm amputation.

Upper extremity prostheses are a tool that can provide assistance with function and/or aesthetics. A passive or cosmetic prosthesis provides an option with a similar size and color of the sound hand. It is the ideal first time option and has been used by the child for several years. It provides an opportunity for the family to develop a consistent wearing pattern with a simple prosthesis. The cosmetic glove can be vinyl or silicone. Silicone gloves can be cleaned more easily. It provides a personalized option for cosmesis.

Amputation of an upper extremity leads to loss of function, affecting the patient physically and mentally. Major amputation is defined as amputation proximal to the wrist joint; minor amputations involve the hand and digits.

Following upper extremity amputation, options to optimize functionality include the use of a prosthesis or undergoing a hand transplant. Patients may choose not to use a prosthesis. Those undergoing stump revision for congenital deficiencies can sometimes function well without using prostheses, preferring the normal tactile sensation of the stump.

Types of prosthesis for upper extremities - The main types of upper extremity prostheses include passive (cosmetic), body powered, and externally powered.

Passive - Passive prostheses focus on improving appearance and do not improve active motor control. Passive prostheses can be static or adjustable. The former cannot move and is limited to basic tasks, such as fastening and stabilizing objects. As an example, the patient can use the prosthesis to stabilize the trunk by balancing the spinal column. The adjustable prosthesis includes some sort of movable mechanism that can be used by adjusting the prosthesis posture with the normal hand, enabling the patient to grasp objects. In many cases, passive prostheses have relatively good appearances and do not impede patients in their daily activities.

The device is made of a continuous piece of silicone that covers the forearm through to the shape of the hand which includes internal adjustable five finger armature, rigid crafted fingernails and custom color matched skin. The armature allows for optimal passive function due to its large range in adjustability while the custom matched skin and nails increase the patients acceptance and use of the prosthesis. It is made of lightweight and durable silicone material that is specifically fabricated to match the size and shape of his opposing hand. It is medically necessary for the patient to perform his basic ADLs (activities of daily living) at home, school and community with an acceptable level of independence that is age appropriate.
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the prosthetic arm is overturned. The medical necessity is substantiated.